Provider Demographics
NPI:1710918628
Name:BRENNEIS, C. BROOKS (PH D)
Entity Type:Individual
Prefix:
First Name:C. BROOKS
Middle Name:
Last Name:BRENNEIS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 PRICE PL STE 203
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3262
Mailing Address - Country:US
Mailing Address - Phone:608-238-2301
Mailing Address - Fax:
Practice Address - Street 1:313 PRICE PL STE 203
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3262
Practice Address - Country:US
Practice Address - Phone:608-238-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI573057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39065800Medicaid